Management of Patients with

Neurologic Dysfunction
 Altered Level of Consciousness (LOC)

 Level of responsiveness and consciousness is the most

important indicator of the patient's condition
 LOC is a continuum from normal alertness and full cognition
(consciousness) to coma
 Altered LOC is not the disorder but the result of a pathology
 Coma: unconsciousness, unresponsiveness, and inability to
arouse
 Altered Level of Consciousness (LOC) (cont.)

 Akinetic mutism: unresponsiveness to the environment, the

patient makes no movement or sound but sometimes opens
eyes
 Persistent vegetative state: patient is devoid of cognitive
function but has sleep–wake cycles
 Locked-in syndrome: patient is unable to move or respond
except for eye movements due to a lesion affecting the pons
 Nursing Process—Assessment of the Patient
With Altered LOC

Verbal response and orientation

Alertness
Motor responses
Respiratory status
Eye signs
Reflexes
Postures
Glasgow Coma Scale
See Table 61-1
 Decorticate

 Decerebrate
Nursing Process—Diagnosis of the Patient With
Altered Level of Consciousness

Ineffective airway clearance

Risk of injury
Deficient fluid volume
Impaired oral mucosa
Risk for impaired skin integrity and impaired
tissue integrity (cornea)
Ineffective thermoregulation
Impaired urinary elimination and bowel
incontinence
Disturbed sensory perception
Interrupted family processes
 Collaborative Problems/Potential
Complications

Respiratory distress or failure

Pneumonia

Aspiration

Pressure ulcer

Deep vein thrombosis (DVT)

Contractures
 Nursing Process—Planning the Care of the
Patient With Altered LOC

 Goals include:
 Maintenance of clear airway
 Protection from injury
 Attainment of fluid volume balance
 Maintenance of skin integrity
 Absence of corneal irritation
 Effective thermoregulation
 Accurate perception of environmental stimuli
 Maintenance of intact family or support system
 Absence of complications
 Interventions

 A major nursing goal is to compensate for the patient's loss of

protective reflexes and to assume responsibility for total patient
care; protection includes maintaining the patient’s dignity and
privacy
 Maintain an airway
 Frequent monitoring of respiratory status including auscultation of
lung sounds
 Position the patient to promote accumulation of secretions and
prevent obstruction of upper airway: HOB elevated 30°, lateral or
semiprone position
 Provide suctioning, oral hygiene, and CPT
 Maintaining Tissue Integrity

 Assess skin frequently, especially areas with high potential for breakdown
 Turn patient frequently; use turning schedule
 Carefully position patient in correct body alignment
 Perform passive range of motion

 Use splints, foam boots, trochanter rolls, and specialty beds as needed
 Clean eyes with cotton balls moistened with saline
 Use artificial tears as prescribed

 Implement measures to protect eyes; use eye patches cautiously as the

cornea may contact patch
 Provide frequent, scrupulous oral care
 Interventions

 Maintain fluid status

 Assess fluid status by examining tissue turgor and mucosa, lab
data, and I&O
 Administer IVs, tube feedings, and fluids via feeding tube as
required: monitor ordered rate of IV fluids carefully
 Maintain body temperature
 Adjust environment and cover patient appropriately
 If temperature is elevated, use minimum amount of bedding,
administer acetaminophen, use hypothermia blanket, give a
cooling sponge bath, and allow fan to blow over patient to
increase cooling
 Monitor temperature frequently and use measures to prevent
shivering
 Promoting Bowel and Bladder Function

 Assess for urinary retention and urinary incontinence

 May require indwelling or intermittent catherization
 Initiate bladder-training program
 Assess for abdominal distention, potential constipation, and bowel
incontinence
 Monitor bowel movements
 Promote elimination with stool softeners, glycerin suppositories, or
enemas as indicated
 Diarrhea may result from infection, medications, or hyperosmolar
fluids
 Sensory Stimulation and Communication

 Talk to and touch the patient and encourage the family to talk to and touch
the patient
 Maintain normal day–night pattern of activity
 Orient the patient frequently
 A patient aroused from coma may experience a period of agitation;
minimize stimulation at this time
 Initiate programs for sensory stimulation
 Allow family to ventilate and provide support
 Reinforce and provide consistent information to family

 Provide referral to support groups and services for the family

 Increased Intracranial Pressure (ICP)

 Monro-Kellie hypothesis: because of limited space in

the skull, an increase in any one skull component—
brain tissue, blood, or CSF—will cause a change in the
volume of the others
 Compensation to maintain a normal ICP of 10 to 20
mm Hg is normally accomplished by shifting or
displacing CSF
 With disease or injury, ICP may increase
 Increased ICP decreases cerebral perfusion, causes
ischemia, cell death, and (further) edema
Brain tissues may shift through the dura and result
in herniation

Autoregulation: refers to the brain’s ability to change

the diameter of blood vessels to maintain cerebral
blood flow

CO2 plays a role; decreased CO2 results in

vasoconstriction, and increased CO2 results in
vasodilatation
Brain With Intracranial Shifts
Brain Herniation with increased ICP
 ICP and CPP

CCP (cerebral perfusion pressure) is closely linked to

ICP

CCP = MAP (mean arterial pressure) – ICP

Normal CCP is 70 to 100

A CCP of less than 50 results in permanent neuralgic

damage
 Manifestations of Increased ICP—Early

Changes in level of consciousness

Any change in condition
 Restlessness, confusion, increasing drowsiness, increased
respiratory effort, and purposeless movements
Pupillary changes and impaired ocular movements
Weakness in one extremity or one side
Headache: constant, increasing in intensity, or
aggravated by movement or straining
 Manifestations of Increased ICP—Late

Respiratory and vasomotor changes

VS: increase in systolic blood pressure, widening of

pulse pressure, and slowing of the heart rate; pulse
may fluctuate rapidly from tachycardia to
bradycardia and temperature increase
 Cushing’s triad: bradycardia, hypertension, and bradypnea

Projectile vomiting
 Manifestations of Increased ICP—Late
(cont.)

Further deterioration of LOC; stupor to coma

Hemiplegia, decortication, decerebration, or

flaccidity

Respiratory pattern alterations including Cheyne-

Stokes breathing and arrest

Loss of brain stem reflexes: pupil, gag, corneal, and

swallowing
Doll’s eyes movement
 Patient With Increased
Intracranial Pressure

Conduct frequent and ongoing neurologic assessment

Evaluate neurologic status as completely as possible
Glasgow Coma Scale
Pupil checks
Assess selected cranial nerves
Take frequent vital signs
Assess intracranial pressure
ICP monitoring
Intracranial Pressure Waves
Location of the Foramen of Monro for
Calibration of ICP Monitoring System
 Collaborative Problems/Potential
Complications

Brain stem herniation

Diabetes insipidus

SIADH

Infection
 Patient With Increased
Intracranial Pressure

Major goals may include:

 Maintenance of patent airway
 Normalization of respirations
 Adequate cerebral tissue perfusion
 Respirations

 Fluid balance
 Absence of infection
 Interventions

 Frequent monitoring of respiratory status and lung sounds and

measure to maintain a patent airway
 Position with the head in neutral position and HOB elevation of 0°
to 60° to promote venous drainage
 Avoid hip flexion, Valsalva maneuver, abdominal distention, or
other stimuli that may increase ICP
 Maintain a calm, quiet atmosphere and protect patient from stress
 Monitor fluid status carefully; during acute phase, monitor I&O
every hour
 Use strict aseptic technique for management of ICP monitoring
system
 Intracranial Surgery

Craniotomy: opening of the skull

 Purposes: remove tumor, relieve elevated ICP, evacuate a
blood clot, and control hemorrhage
Craniectomy: excision of a portion of the skull
Cranioplasty: repair of a cranial defect using a plastic
or metal plate
Burr holes: circular openings for exploration or
diagnosis, to provide access to ventricles, for shunting
procedures, to aspirate a hematoma or abscess, or to
make a bone flap
Supratentorial Approach for
Cranial Surgery
Infratentorial Approach for
Cranial Surgery
Transsphenoidal Approach for
Cranial Surgery
Burr Holes
 Preoperative Care—Medical Management

 Preoperative diagnostic procedures may include CT scan, MRI,

angiography, or transcranial Doppler flow studies
 Medications are usually given to reduce risk of seizures
 Corticosteroids, fluid restriction, hyperosmotic agents
(mannitol), and diuretics may be used to reduce cerebral edema
 Antibiotics may be administered to reduce potential infection
 Diazepam may be used to alleviate anxiety
 Preoperative Care—Nursing Management

Obtain baseline neurologic assessment

Assess patient and family understanding of

and preparation for surgery

Provide information, reassurance, and

support
 Preoperative Care—Nursing Management

Postoperative care is aimed at detecting and

reducing cerebral edema, relieving pain,
preventing seizures, and monitoring ICP and
neurologic status

The patient may be intubated and have

arterial and central venous lines
 Postoperative Care

Postoperative care is aimed at detecting and

reducing cerebral edema, relieving pain,
preventing seizures, and monitoring ICP and
neurologic status
The patient may be intubated and have
arterial and central venous lines
 Nursing Process—Assessment of the
Patient Undergoing Intracranial Surgery

 Careful, frequent monitoring of respiratory function, including

ABGs
 Monitor VS and LOC frequently; note any potential signs of
increasing ICP
 Assess dressing and for evidence of bleeding or CSF drainage

 Monitor for potential seizures; if seizures occur, carefully record and

report them
 Monitor for signs and symptoms of complications
 Monitor fluid status and laboratory data
 Nursing Process—Diagnosis of the Patient
Undergoing Intracranial Surgery

Ineffective cerebral tissue perfusion

Risk for imbalanced body temperature
Potential for impaired gas exchange
Disturbed sensory perception
Body image disturbance
Impaired communication (aphasia)
Risk for impaired skin integrity
Impaired physical mobility
 Collaborative Problems/Potential
Complications

Increased ICP

Bleeding and hypovolemic shock

Fluid and electrolyte disturbances

Infection

Seizures
Nursing Process—Planning the Care of the
Patient Undergoing Intracranial Surgery

Major goals may include:

 Improved tissue perfusion
 Adequate thermoregulation

 Normal ventilation and gas exchange

 Ability to cope with sensory deprivation

 Adaptation to changes in body image

 Absence of complications
 Maintaining Cerebral Perfusion

 Monitor respiratory status; even slight hypoxia or hypercapnia can

affect cerebral perfusion
 Assess VS and neurologic status every 15 minutes to one hour

 Implement strategies to reduce cerebral edema; cerebral edema

peaks in 24 to 36 hours
 Implement strategies to control factors that increase ICP

 Avoid extreme head rotation

 Head of bed may be flat or elevated 30° according to needs related

to the surgery and surgeon’s preference
 Interventions

 Regulate temperature
 Cover patient appropriately
 Treat high temperature elevations vigorously; apply ice bags, use
hypothermia blanket, and administer prescribed acetaminophen
 Improve gas exchange
 Turn and reposition the patient every 2 hours
 Encourage deep breathing and incentive spirometry
 Suction or encourage coughing cautiously as needed (suctioning and
coughing increase ICP)
 Humidify oxygen to help loosen secretions
 Interventions (cont.)

 Sensory deprivation
 Periorbital may impair vision, so announce your presence to avoid
startling the patient; cool compresses over eyes and HOB
elevation may be used to reduce edema if not contraindicated
 Enhance self-image
 Encourage verbalization
 Encourage social interaction and social support
 Pay attention to grooming
 Cover head with turban and later with a wig
 Interventions (cont.)

Monitor I&O, weight, blood glucose, serum, urine

electrolyte levels, osmolality, and urine specific gravity
Preventing infections
 Assess incision for signs of hematoma or infection
 Assess for potential CSF leak
 Instruct patient to avoid coughing, sneezing, or nose blowing,
which may increase the risk of CSF leakage
 Use strict aseptic technique
Patient teaching for self-care
 Seizures

Abnormal episodes of motor, sensory, autonomic, or

psychic activity (or a combination of these) resulting
from a sudden, abnormal, uncontrolled electrical
discharge from cerebral neurons
Classification of seizures: see Chart 61-3
 Partial seizures: begin in one part of the brain
 Simple partial: consciousness remains intact
 Complex partial: impairment of consciousness
 Generalized seizures: involve the whole brain
 Specific Causes of Seizures

 Cerebrovascular disease
 Hypoxemia
 Fever (childhood)
 Head injury
 Hypertension
 Central nervous system infections
 Metabolic and toxic conditions
 Brain tumor
 Drug and alcohol withdrawal
 Allergies
Tonic-clonic contractions
 Plan of Care for a Patient
Experiencing a Seizure

Observation and documentation of patient signs and

symptoms before, during, and after seizure

Nursing actions during seizure for patient safety and

protection

After seizure care, prevent complications

See Chart 61-4

Guidelines for Seizure Care
 Headache

Also called cephalgia, it is one of the most common

physical complaints
Primary headache has no known organic cause and
includes migraine, tension headache, and cluster
headache
Secondary headache is a symptom with an organic
cause such as a brain tumor or aneurysm
Headache may cause significant discomfort for the
person and can interfere with activities and lifestyle
 Assessment of Headache

 A detailed description of the headache is obtained

 Include medication history and use

 The types of headaches manifest differently in different persons,

and symptoms in one individual may also may change over time

 Although most headaches do not indicate serious disease,

persistent headaches require investigation
 Assessment of Headache (cont.)

Persons undergoing a headache evaluation require a

detailed history and physical assessment with
neurological exam to rule out various physical and
psychological causes

Diagnostic testing may be used to evaluate the

underlying cause if the neurologic exam is abnormal
 Nursing Management of Headache—Pain

Provide individualized care and treatment

Prophylactic medications may be used for recurrent
migraines
Migraines and cluster headaches require abortive
medications instituted as soon as possible with onset
Provide medications as prescribed
Provide comfort measures
 Quiet, dark room
 Massage
 Local heat for tension
 Nursing Management of Headache—
Teaching

 Help patient identify triggers and develop preventive strategies

and lifestyle changes for headache prevention
 Provide medication instruction and treatment regimen
 Implement stress reduction techniques
 Implement nonpharmacologic therapies
 Provide follow-up care
 Encourage healthy lifestyle and health promotion activities
Types of IC Hematomas